Monday, December 24, 2007

Off for Christmas

Last year I wrote about Christmas in the hospital. This year I’m home in Alaska for the first time in three years, taking advantage of my luck in having the holiday off. We get so used to working weekends and holidays in medicine, helping others to stay healthy, that having Christmas week to ourselves seems extravagant, like a special bonus. It feels good to put up the white coat for a week, to escape the wards. Too much time in the hospital, in the face of unrelenting illness, can make you forget what life is supposed to be like, what you’re fighting for in the first place.

As physicians, we stand at the intersection between the constructed world of our daily lives, which is ordered, meaningful, even protected, and the cold, impartial reality of the natural world. In Alaska the divide is particularly evident – though our lives are filled with the normal stuff of human existence – friends, family, food, films, music, plans, jobs, dreams, they are lived in the shadow of the simple reality that with one misstep – a car breakdown in mid-winter, a frozen set of water pipes, everything could come crashing down. It happens rarely; mostly we are allowed to live our lives peacefully, but on occasion the natural world forcefully collides with the quotidian one, obliterating it. A woman is diagnosed with breast cancer. A tsunami hits Thailand. What we’re fighting for is to keep our safe, purposeful, constructed worlds, of competitive sports and holiday parties, intact, shielded from nature’s unwelcome intrusions.

We’re somewhat successful. Most people live a rather insular existence, sheltered from natural disaster. The well are frustrating to care for because they think that they are impervious to illness, that they will never get sick; as a result, they tend poorly to their bodies. They feel that the world is fundamentally fair. As doctors we are fallen from this illusion. We live in the midst of the natural world’s devastation. We know that anyone can get sick, can up and die. A young man at the height of his powers, contributing greatly to society, raising a family, can collapse suddenly without warning.

The medical fight is an important one, but seeing sickness and disease every day wears on you. Being greeted a daily good morning by failing kidneys, bid good evening by an ailing heart, paid unexpected nightly visits by struggling lungs: it takes a toll. The curse of the chronically ill is to experience pain that nags just enough to constantly remind the sufferers that they are ill. The curse of the doctor is to be cognizant of his patients' sufferering. On interval, a break is needed, an escape from the hospital, a vacation.

This week I’m going to forget that disease even exists. I’m going to experience Christmas the way I hope my patients do: oblivious to hardship and suffering. People say to live each day like it’s your last, but that’s rubbish, or at least, it’s lousy advice for a vacation. How about relaxation instead? True luxury is to live as if you were going to live forever, to dally with each and every trivial pursuit. To watch movies and feel no guilt about how you could be better spending your time, to sleep in late, to indulge yourself completely: that is vacation at its best. That is how I intend to spend this Christmas.

Friday, December 14, 2007

One's own authority

One of the sobering things about the third year of residency is coming over that sophomoric high of second year, when you were finally able to start taking care of patients somewhat autonomously. Where in second year you think “yes, I nailed the management of that hypertensive urgency,” in third year you start to wonder, does hypertensive urgency even exist? Was it necessary to admit that patient to the ICU, place an arterial line, and use an iv infusion to bring down the blood pressure of a completely asymptomatic patient? You come to appreciate that you know very little, and most of what you do know is suspect.

As I transition into becoming an attending, I’ve been paying more attention to what I know and what I don’t. One of the things I’ve realized is that knowing something isn’t enough; you have to know where you learned it. A piece of information without a source is like a carton of milk without an expiration date: you don’t really know if it’s safe for consumption, and by the time you’ve found out it’s too late. Whether a pearl came from Attending A or Attending E, from a pharmaceutical rep or a published paper, it carries a vastly different weight. When you confuse where you learned something, you open yourself up to all kinds of trouble.

Ideally, knowledge in medicine is evidence based, originating from scientific studies and grounded in some type of objective, reproducible data. In reality, though, medical training is an apprenticeship; our education occurs in the work environment, at the hands of our mentors. For this to succeed, it requires our mentors to have a certain authority. We must be able to trust that when they say something, they know what they are talking about, that their input is based upon experience and knowledge of the literature. That way we don’t have to challenge every little assertion, which would be impossible to do anyway.

Even so, taking things on the authority of others only gets you so far. At some point you have to stand up and take ownership of your own body of knowledge. As an aspiring attending, that means becoming your own authority, which can entail going back and relearning everything that you know. It’s a slow and frustrating process, one that I wonder if I ever will complete; indeed, some of my current attendings still cite their own former attendings when teaching me things. Years into practice, they still do things based upon the authority of those former mentors.

Perhaps ‘relearning’ medicine is a mischaracterization, it’s really that you have to make it your own, the way a dancer first learns and then possesses choreography. You have to integrate it into the fabric of your being so that you can wield it rather than simply regurgitate it. I guess that’s what third year is for. That’s what the seventy first case of pneumonia is for – for the gelling process to occur. By working through it now and building the foundation just a little bit firmer, maybe my form will actually stick when the molding is removed next year.

Friday, December 07, 2007

Notice of employment

The ‘sorry I haven’t posted in a long time, I promise to be better’ post is such a common one in the blogosphere that there should be a pre-written template or form-post just for the purpose. Simply write in your excuse, and all of the other pleasantries will be taken care of for you. Mine currently is that I’ve been traveling – job interviewing, to be exact. I was looking at hospitalist jobs in the Pacific Northwest and actually found a good one; I’ll be relocating to the greener, rainier Washington this summer. Also, I was rushing to finish a research project on time and trying to meet the deadline for The Great Sufjan Song Xmas Xchange. Have you ever tried to write a Christmas song? It’s harder than it sounds – Santa, Rudolph, Frosty, and baby Jesus have all been done. I ended up writing some silly thing about imagining that Christmas was in a season other than winter.

Anyway, with employment secured and some of my other projects taken care of, maybe there will be more time for blogging. I hope so. A few thoughts have been bouncing around in my head, and they are dying to get out.